Clinical Pearls & Morning Reports
Published July 11, 2018
Mood symptoms including a high energy level, a decreased need to sleep, racing thoughts, a tangential thought process, rapid speech, and impulsive behavior, reflect a manic episode. Read the latest Case Records of the Massachusetts General Hospital article here.
Q: At what age does the onset of mania associated with bipolar disorder commonly occur?
A: Bipolar disorder is characterized by the occurrence of a manic episode that does not have another medical cause. Patients with bipolar disorder vacillate between manic episodes and euthymia, and they often (but not always) have major depressive episodes, as well. Although mania associated with bipolar disorder may first occur at any age during adulthood, it usually occurs within one of two age ranges: the most common age at the onset of mania is between 16 and 25 years, but there is a second peak between 46 and 55 years.
Q: What other psychiatric or neurologic illnesses may include or mimic mania?
A: Schizoaffective disorder is characterized by a baseline of chronic psychotic illness punctuated with mood episodes (depression, mania, or both). In patients with schizoaffective disorder, the psychotic symptoms persist despite resolution of the mood episodes. Delirium — which is marked by acute fluctuations in attention, awareness, and cognition — may resemble a manic episode, with shared features including decreased sleep, disorganized thinking and speech, impulsivity, distractibility, and hallucinations. Delirium is always caused by an underlying medical condition. Patients with dementia may present with impulsivity, executive dysfunction, mood and sleep disturbance, and personality changes, findings that mimic mania.
A: Mania can be caused by a medical illness. Endocrine disorders — including hyperthyroidism, hypothyroidism, and Cushing’s disease — must be considered. A wide range of neurologic conditions, including vascular illness, can cause mania. Stroke most frequently causes depression, but emotional lability, personality changes, psychosis, and mania are all possible psychiatric manifestations of stroke. Mania is more likely to develop in patients with stroke lesions on the right side of the brain, but it can also result from a lesion on the left side of the brain. A stroke associated with mania is usually located in the right ventral prefrontal cortex, right medial frontal lobe, or right basal ganglia. Mania most frequently develops within a few days after a stroke occurs, but it can develop up to 2 years after a stroke. Medications that are known to induce mania include antidepressants, glucocorticoids, levodopa, antibiotic agents (especially macrolides, fluoroquinolones, and isoniazid), and sympathomimetic agents.
A: The initial management of poststroke mania revolves around minimizing risk factors for the development of additional stroke. Pharmacologic treatment of poststroke affective disorders is similar to treatment for primary affective disorders. Lithium or valproate can be used as monotherapy. Lithium may also protect against further neuronal death after an infarct. Second-generation antipsychotics, benzodiazepines, and gabapentin can be used as adjunct medications while the dose of the mood stabilizer is adjusted to the therapeutic level.